Wiki Teaching Physician

Which guidelines is she referring to as not needing to be followed?

For commercial patients, the provider would need to follow any guidelines stipulated in any contracts the provider has with that payer. Self pay patients, theoretically at least, can be billed for services as the provider sees fit since no claims are being generated and therefore nothing is being coded.

It may be possible to 'get away' with something like this, but it's inadvisable to treat different patients differently based on coverage or ability to pay. After all, a patient may have coverage that the provider is not aware of at the time of service, or may in some cases retroactively get coverage, and then the provider, by not following the guidelines, would be putting herself in a position of being at risk for having inappropriately documented or billed something that did not meet a payer's requirements. I don't understand why any provider would selectively observe certain guidelines only for certain types of patients - it just makes no sense to me when I hear something like this.
 
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Which guidelines is she referring to as not needing to be followed?

For commercial patients, the provider would need to follow any guidelines stipulated in any contracts the provider has with that payer. Self pay patients, theoretically at least, can be billed for services as the provider sees fit since no claims are being generated and therefore nothing is being coded.

It may be possible to 'get away' with something like this, but it's inadvisable to treat different patients differently based on coverage or ability to pay. After all, a patient may have coverage that the provider is not aware of at the time of service, or may in some cases retroactively get coverage, and then the provider, by not following the guidelines, would be putting herself in a position of being at risk for having inappropriately documented or billed something that did not meet a payer's requirements. I don't understand why any provider would selectively observe certain guidelines only for certain types of patients - it just makes no sense to me when I hear something like this.

Thank you, Thomas. I agree. The provider is stating she can use a resident to see a patient for a psych consult in her place for non-government patients. I see this as treating patients differently based upon payer. She is adamant that other health systems, Duke specifically, do this all the time. We have always educated our providers to follow CMS guidelines, which state the provider should also see the patient and document accordingly. She is essentially getting free labor out of the residents and getting paid for it. My problem now is finding something in writing to support me.
 
I would think her state Medical Board and/or her Malpractice Company might have a few things to say about it. After all, she is signing off on their work without seeing the patient herself (which Medicare, of course, requires). So would her state medical board consider that the normal standard of care? Probably not.

Another thought: When the claim is sent in to the commercial carrier, she is attesting that she personally performed the work billed, or it was an incident-to situation. New patients (consult) do not qualify for incident-to, and neither does inpatient work.

If I were a private pay patient, and I got a bill from someone who had not seen me, I would be asking them for their report. If their report indicates that someone else did the work (like a resident), I would be informing them that not only would I not be paying them, but that I would be opening inquiries with the medical board and the hospital. Yes, I'm THAT person.
 
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